OTHER POLYGRAPH LICENSES State Number Dates held OTHER PROFESSIONAL ORGANIZATIONAL MEMBERSHIPS Organization name From when to when? MILITARY SERVICE Branch Dates of Service Discharge Type
Please answer the following question truthfully and completely. If additional space is needed, please utilize the Continuation Page at the end of this application.
A. Have you ever been investigated or charged with a criminal offense? ( ) Yes ( ) No If yes, please explain below. B. Have you ever been refused a bond? ( ) Yes ( ) No ( ) N/A If yes, please explain below. C. Have you ever been discharged from any employment? ( ) Yes ( ) No If yes, please explain below. D. Have you ever been expelled from membership in any organization or society? ( ) Yes ( ) No If yes, please explain below. E. Have you now or have you ever been a member of a subversive organization? ( ) Yes ( ) No If yes, please explain below. F. Have you ever been denied/refused/revoked a professional membership of any organization? ( ) Yes ( ) No If yes, please explain below. G. Have you been fired for cause from a government agency? ( ) Yes ( ) No If yes, please explain below. REFERENCES (Please include names and addresses for 4 personal/professional references.
I understand that I will not receive, and I am not entitled to information collected during the course of my application process, and I further understand the information collected will be used in the evaluation process for my membership with the Arizona Polygraph Association (AzPA). I affirm that I have completed this application on my own and for myself and information provided is truthful and honest. I agree to hold said Arizona Polygraph Association, its members, examiners, officers, and agents free from damage, liabilities or complaint, by reason of any action they, or any of them, take in connection with this application.
I will be notified upon a successful preliminary review of my application and will provide sample polygraph charts for evaluation by the AzPA membership committee at which time I will also provide a $75.00 membership application fee via check or money order made payable to the AzPA.